Healthcare Provider Details

I. General information

NPI: 1336450048
Provider Name (Legal Business Name): ANGELA GILLESPIE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA NELSON PA-C

II. Dates (important events)

Enumeration Date: 06/28/2010
Last Update Date: 05/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MCCLINTOCK DRIVE SUITE 202
BURR RIDGE IL
60527-0872
US

IV. Provider business mailing address

901 MCCLINTOCK DRIVE SUITE 202
BURR RIDGE IL
60527-0872
US

V. Phone/Fax

Practice location:
  • Phone: 888-220-6432
  • Fax: 630-654-4253
Mailing address:
  • Phone: 888-220-6432
  • Fax: 630-654-4253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085003762
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: